1. Chronic RhinoSinusitis- State of the Art
Gary Kroukamp

2. Definition:
>3 months of symptoms of sinusitis

4. Case Study: 55 yo man 3 episodes of acute sinusitis since last winter
Treated with antibiotics
Resolution of acute sx
continues to have pressure “sinus” headache, nasal congestion, poor smell, and intermittent rhinorrhea.

5. Chronic Rhinosinusitis?
History
Duration
Allergic Symptoms?
Smoker?
Presenting symptoms
Examination

6. The Dairy and Wheat Myth!
Milk mucous sensation
Inhaled vs Ingested allergen

7. Common Presenting Symptoms
nasal obstruction 94%
postnasal drip %
facial pain & headache 90%
rhinorrhoea 61%
hyposmia / anosmia

8. Physical examination:
Purulent rhinorrhoea
Polyps
Complications?

9. Scope
Pus
Polyps
Oedema

10. Pathophysiology: Obstruction of osteomeatal complex
Impaired mucociliary clearance
Biofilm
Superantigen
Inflammatory Cascade

11. Anatomical variants: deviated nasal septum concha bullosa
ethmoid bulla
other middle turbinate anomalies
Agger nasi cells
Haller cells

12. Underlying diseases: asthma cystic fibrosis ciliary dysmotility
immuno-compromised:
chemotherapy
transplant
immuno-deficiency

13. CT scan?
Sinusitis or not?
Surgical Planning

14. Normal CT

15. Abnormal CT

16. Really Abnormal CT

17. Objectives for treatment:
Improve Symptoms
Treat Infection
Resume normal sinus physiology
Prevent complications

18. Microbiology: Anaerobes Staphylococcus aureus Streptococcus
Haemophilus Influenzae
Moraxella catarrhalis

19. Treatment options: Antibiotics Oral Steroids Nasal Steroids Saline
sufficient duration
Oral Steroids
Nasal Steroids
Saline
Anti –leucotrienes (Singulair) – not shown to be effective

20. Antibiotics:
Controversial- none approved in Canada as indication for CRS
If there is pus!
Amoxicillin-clavulanic acid - Augmentin
Fluoroquinolones - Moxifloxacin
Macrolides - Ketek

21. Steroids? Oral short course IL-5 & IL-13
Reduce tissue inflammation, oedema

22. Nasal Steroids
Treatment mainstay!
Compliance!
3 months!
Chronic use…

23. Future Research The magic bullet! Anti-inflammatory biological
Anti-interleukin

24. Referral
Failure of treatment
Complications

25. “Sinus headache” Headache is complicated Multifactorial!
Sinus headache/pain does NOT mean sinusitis
MUST have proper evaluation

26. FESS – Functional Endoscopic Sinus Surgery
Patient selection crucial! – Don’t operate for headache!
Abnormal CT
Restore sinus function
Improve ventilation and drainage
Open the ostium
Remove the obstructed honeycomb (ethmoids)
Clear obstruction

27. FESS – Surgical Aims Restore sinus function
Improve ventilation and drainage
Open the ostium
Remove the obstructed honeycomb (ethmoids)
Clear obstruction

28. Evidence/Validation?
Impact of Functional Endoscopic Sinus Surgery on Symptoms and Quality of Life in Chronic Rhinosinusitis†Michael Damm MD, Gero Quante MD, Markus Jungehuelsing MD, Eberhard Stennert MD – Laryngoscope Jan 2009
Recalcitrant Rhinosinusitis, the diagnosis and treatment and evaluation of results – Rhinology 2010
EPOS -